Cooperative Alliance Application
For Admission
Name: __________________________ ______________________ ___________________________ ________________
First Middle Last Suffix
Have you ever applied for admission or enrolled in classes at Rose State College before? Yes No
If yes, what was the last semester/year of your enrollment/application at Rose State College? __________________________________
Please check one classification below that best represents your enrollment at Rose State College for this application:
Current high school student Home school or unaccredited high school student
GED / Non-high school graduate Active duty military
Adult high school graduate – no previous college work Adult high school graduate – previous college work
Special / Non-Degree seeking student Transfer from another college or university
Undocumented Immigrant Student International non-immigrant Visa holder
High school students who plan to request college credit for courses taught through an approved Cooperative Alliance
Agreement must complete this form, meet the following State Regents’ policy requirements and submit all required
documentation:
 Submit an ACT score of at least 19 or an ACT Plan score of at least a 15 or a high school GPA of at least 2.5.
 Submit a signed Parent Statement of Understanding – Counselor/Principal Recommendation form.
 Submit a current official high school transcript to Rose State College.
Semester and year applying for (please select one): Fall 20______ Spring 20______ Summer 20______
Are you on academic probation at another school? Yes No
Are you on academic suspension at another school? Yes No
Date of Birth: ______ / ______ / _______ Place of Birth ______________________________ / _____________
Month Day Year City State
Social Security Number __________ - _______ - __________ Gender: Male Female
Home Phone Number (_______) ________ - ___________
Permanent Home Mailing Address_________________________________________________________________________________
City________________________________ State_________________ Zip Code ______________
Are you a US Citizen? Yes No Is English your second language? Yes No
If you are not a US citizen, what is your country of citizenship? __________________________________________________________
If you hold a non-immigrant Visa, what category is the Visa (ex: F-1, J-1, etc…) ____________________________________________
If English is your second language, have you taken a recent International TOEFL or IELTS exam within the past 2 years?
*If yes, please submit official score report. Yes No
Are you a Resident Alien? Yes No If yes, Resident Alien #_________________________________
Page 1 of 2
REV. 7/12/2010
Cooperative Alliance Application
For Admission
Name: __________________________ ______________________ ___________________________ ________________
First Middle Last Suffix
(The following ethnicity information is optional but is requested for reporting purposes only in accordance with the 1964 Civil
Rights Act, Title VI, as amended. Please check the appropriate box)
Do you consider yourself Hispanic or Latino? Yes No
Select one or more of the following categories to describe you.
Non-Resident Alien American Indian or Alaskan Native Asian
Black or African American Native Hawaiian or Pacific Islander White
If you are American Indian, what is your tribe’s name and Blood Line? ___________________________________________________
Mother’s Tribe Father’s Tribe Both Unknown
Are you currently also earning college credit or enrolling in college courses at another college or university? Yes No
If yes, what school? _________________________________________________________________________________________
List all colleges ever attended _____________________________________ ________________________________________
*please provide official transcripts
_____________________________________ ________________________________________
High School attended ___________________________________________ City _______________________ State _____________
What is your high school graduation date? Month ____________________ Year _____________
Have you earned a GED? Yes No If yes, what year did you earn your GED? ________________________
Are your ACT scores already on file with Rose State College? Yes No
Emergency Contact’s Name ___________________________________________ Relationship to student ______________________
Emergency Contact Home Address ________________________________________________________________________________
City________________________________ State_________________ Zip Code ______________
Emergency Contact Phone Number (_______) ________ - ___________
Are you an Oklahoma resident? Yes No
If you are an Oklahoma resident, how long have you lived here? Years ___________ Months __________
If you are not an Oklahoma resident, what state are you a resident of? State ________________________
Are you active duty military personnel? Yes No If yes, branch of service? _________________
Are you a military veteran? Yes No If yes, branch of service? _________________
Are you the dependent of active duty military personnel? Yes No If yes, branch of service? _________________
If you answered yes to either military question, in what state is the active member stationed? __________________________________
I agree to abide by the rules, regulations and policies of Rose State College. I certify that the above information is true and
correct to the best of my knowledge. I request to receive cooperatively earned college credit. Failure to submit correct
information may result in dismissal from RSC.
Student Signature___________________________________________________________________ Date_____________________
Office Use Only:
Admit Code: Residency Code: High School code: Last College code: Entered by: Date:
Page 2 of 2
REV. 7/12/2010

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Cooperative Alliance Application
For Admission
Name: __________________________ ______________________ ___________________________ ________________
First Middle Last Suffix
Have you ever applied for admission or enrolled in classes at Rose State College before? Yes No
If yes, what was the last semester/year of your enrollment/application at Rose State College? __________________________________
Please check one classification below that best represents your enrollment at Rose State College for this application:
Current high school student Home school or unaccredited high school student
GED / Non-high school graduate Active duty military
Adult high school graduate – no previous college work Adult high school graduate – previous college work
Special / Non-Degree seeking student Transfer from another college or university
Undocumented Immigrant Student International non-immigrant Visa holder
High school students who plan to request college credit for courses taught through an approved Cooperative Alliance
Agreement must complete this form, meet the following State Regents’ policy requirements and submit all required
documentation:
 Submit an ACT score of at least 19 or an ACT Plan score of at least a 15 or a high school GPA of at least 2.5.
 Submit a signed Parent Statement of Understanding – Counselor/Principal Recommendation form.
 Submit a current official high school transcript to Rose State College.
Semester and year applying for (please select one): Fall 20______ Spring 20______ Summer 20______
Are you on academic probation at another school? Yes No
Are you on academic suspension at another school? Yes No
Date of Birth: ______ / ______ / _______ Place of Birth ______________________________ / _____________
Month Day Year City State
Social Security Number __________ - _______ - __________ Gender: Male Female
Home Phone Number (_______) ________ - ___________
Permanent Home Mailing Address_________________________________________________________________________________
City________________________________ State_________________ Zip Code ______________
Are you a US Citizen? Yes No Is English your second language? Yes No
If you are not a US citizen, what is your country of citizenship? __________________________________________________________
If you hold a non-immigrant Visa, what category is the Visa (ex: F-1, J-1, etc…) ____________________________________________
If English is your second language, have you taken a recent International TOEFL or IELTS exam within the past 2 years?
*If yes, please submit official score report. Yes No
Are you a Resident Alien? Yes No If yes, Resident Alien #_________________________________
Page 1 of 2
REV. 7/12/2010
Cooperative Alliance Application
For Admission
Name: __________________________ ______________________ ___________________________ ________________
First Middle Last Suffix
(The following ethnicity information is optional but is requested for reporting purposes only in accordance with the 1964 Civil
Rights Act, Title VI, as amended. Please check the appropriate box)
Do you consider yourself Hispanic or Latino? Yes No
Select one or more of the following categories to describe you.
Non-Resident Alien American Indian or Alaskan Native Asian
Black or African American Native Hawaiian or Pacific Islander White
If you are American Indian, what is your tribe’s name and Blood Line? ___________________________________________________
Mother’s Tribe Father’s Tribe Both Unknown
Are you currently also earning college credit or enrolling in college courses at another college or university? Yes No
If yes, what school? _________________________________________________________________________________________
List all colleges ever attended _____________________________________ ________________________________________
*please provide official transcripts
_____________________________________ ________________________________________
High School attended ___________________________________________ City _______________________ State _____________
What is your high school graduation date? Month ____________________ Year _____________
Have you earned a GED? Yes No If yes, what year did you earn your GED? ________________________
Are your ACT scores already on file with Rose State College? Yes No
Emergency Contact’s Name ___________________________________________ Relationship to student ______________________
Emergency Contact Home Address ________________________________________________________________________________
City________________________________ State_________________ Zip Code ______________
Emergency Contact Phone Number (_______) ________ - ___________
Are you an Oklahoma resident? Yes No
If you are an Oklahoma resident, how long have you lived here? Years ___________ Months __________
If you are not an Oklahoma resident, what state are you a resident of? State ________________________
Are you active duty military personnel? Yes No If yes, branch of service? _________________
Are you a military veteran? Yes No If yes, branch of service? _________________
Are you the dependent of active duty military personnel? Yes No If yes, branch of service? _________________
If you answered yes to either military question, in what state is the active member stationed? __________________________________
I agree to abide by the rules, regulations and policies of Rose State College. I certify that the above information is true and
correct to the best of my knowledge. I request to receive cooperatively earned college credit. Failure to submit correct
information may result in dismissal from RSC.
Student Signature___________________________________________________________________ Date_____________________
Office Use Only:
Admit Code: Residency Code: High School code: Last College code: Entered by: Date:
Page 2 of 2
REV. 7/12/2010